Opening the “Black Box” of GME Costs and Benefits: A Conceptual Model and a Call for Systematic Studies

摘要

At the heart of the current debate on financing graduate medical education (GME) is a seemingly simple question, how much does it cost hospitals and other health care providers to participate in GME? The answer has important implications for both the number and types of residency programs offered and the level of federal support needed to meet future physician workforce needs. Yet the question itself is not well understood, and information needed to answer it is lacking. Despite the importance that the net costs of operating individual residency training programs might have for the decisions sponsoring institutions make about operating these programs, the Institute of Medicine's (IOM) recent report, Graduate Medical Education That Meets the Nation's Health Care Needs, concludes that there is little understanding of the bottom-line financial impact of programs in various specialities, and that the costs and benefits of providing resident education are a “black box.”1 As a step toward opening up this “black box,” the IOM report recommended data collection and detailed reporting on the use of Medicare GME funds.1;Medicare Funding for GME Medicare is the primary source of federal support for GME. Medicare funding flows to teaching hospitals through direct GME (DGME) payments for the direct costs of operating residency training programs (such as resident salaries, teaching physician compensation, and costs of maintaining the GME office), and through indirect medical education (IME) payments for additional costs of teaching hospitals that are not otherwise captured by the prospective payment system for inpatient services.2 Both DGME and IME payments are formula-driven and do not account for any potential differences in the financial impact of different specialty programs on teaching hospitals. A key policy issue is whether Medicare support for GME should be restructured to differentiate between programs that are less costly to operate, or are self-sustaining, and those that are more costly.2,3 Presently, there are insufficient studies documenting the net costs of operating different types of residency training programs, and we lack the cost information to accurately target federal residency training support to achieve physician workforce objectives. Currently there is little empirical data to inform the debate over the appropriate level of federal funding, how it is allocated across specialties, and how funds are distributed. The IOM report envisions that a new GME policy council, housed within the US Department of Health and Human Services, would be responsible for prioritizing the GME fund allocations across identified domains, such as specialty and subspecialty programs, geographic areas, and types of sponsoring institutions.1 This requires empirical data on actual costs to structure equitable payments and provide incentives for programs that meet future physician workforce needs. In this issue of the Journal of Graduate Medical Education, a study by Iannuzzi et al4 is an important contribution to the question of how an internal medicine residency program affects a hospital system's costs of caring for inpatients. Findings for the resident-hospitalist team relative to the midlevel practitioner-hospitalist team performance on length of stay and direct patient care costs are notable and should encourage other teaching hospitals to undertake similar analyses. However, such analyses address just 1, albeit important, aspect of the financial impact question. Perhaps most important for internal residency programs, an assessment of financial impact should include consideration of the impact that residents have on attending physician productivity and clinical revenues, particularly in ambulatory clinics. In addition to the added benefits arising from Medicare support of resident education, which the authors discussed, there are indirect benefits that are more difficult to measure but which are important to the overall economics of operati